Oral/Maxillofacial Surgery and Dental Implants
Dedicated to providing top-quality outpatient care to all of Southern Illinois,
in a relaxing, modern, and state-of-the-art facility.
Click here to download a printable copy of our Patient Registration form. It may also be filled out electronically and then printed.
Click here to download a printable copy of our Health History form. It may also be filled out electronically and then printed.
***Forms must be filled out using Adobe Reader, which is available free by clicking here. If the link does not work, Google search “Adobe Reader download.” Make sure to uncheck any “offer” box to avoid downloading additional software to your computer.
***Some internet browsers, such as Mozilla Firefox and Google Chrome have a built in PDF reader that may not allow you to fill out the form within the browser window. If this is the case, simply save the form to your desktop and then reopen it in Adobe Reader. Alternatively, you may disable the PDF preview feature in your browser.